In 1913, when the present King’s College Hospital was built, diabetes was largely untreatable and Type 1 (insulin dependent) a fatal disease. Within two months of being diagnosed with Type 1 diabetes in November 1920, Dr Robin Daniel Lawrence (RDL 1892-1968), then a trainee surgeon at King’s College Hospital, turned to biochemical research on diabetes at a time when he was slowly dying of it. He went to Florence expecting to die. However, the successful extraction of insulin in Toronto in 1921 by Frederick Banting and Charles Best (who became a very great friend of RDL) led to treatment of their first patient in 1922, at one stroke converting a fatal disease into a chronic disease. In Florence, RDL responded to a telegram from Dr GA Harrison, biochemist at King’s, with the brief message “we’ve got insulin-come back quick”. He was one of the earliest patients in Britain to receive an insulin injection, first given on 22nd May 1923 in King’s A & E department because there were no available hospital beds! Thereafter RDL became one of the world’s leading diabetes physicians, and the specialty of diabetes was born, with Lawrence’s department at King’s as its leading exponent.
RDL never ceased to undertake scientific and clinical research, often on himself, at a time when almost nothing was known regarding the use of insulin, and his book “The Diabetic Life” went through 17 editions between 1925 and 1965 helping countless people with wise advice from personal experience. He founded the Diabetic Association (now Diabetes UK), with help from one of his patients, HG Wells. It was the first organisation of its kind to establish links between patients, carers and health professionals. RDL also became the founding president of the International Diabetes Federation (1958).
During the 1930s and 1940s there was increasing awareness that long term survival with diabetes can be accompanied by a range of serious complications, which sometimes affect the eyes, kidneys, nerves or arteries. At that time there were no methods available either to prevent or treat these complications. Now as we celebrate this centenary, it has become possible to delay their onset, slow their progression, and if they do occur, diminish their impact. This account focuses on innovations at King’s.
It is difficult now to imagine the anguish once felt when an individual was diagnosed as having diabetes. Mrs BJ, a Herne Hill resident and one of Lawrence’s patients was diagnosed with diabetes at the age of 10 in 1932. Writing 60 years later she reflected then that she had “heard many tales about the trauma of diabetics who had babies, and I made up my mind I would not have any”. She was right: foetal mortality in 1942 was very high at 33%, and up to 70% in those whose pregnancies were unsupervised. Disastrous outcomes such as these led to the idea that specialist consultants should see patients together in joint clinics. Dr Wilfred Oakley (1905—1998, Lawrence’s successor) collaborated with Sir John Peel (Royal Obstetrician and obstetrician at Kings), and later by Mr Michael Brudenell, (also a Dulwich resident), and many others since, ensuring joint expertise linked to a continuity of care. Results improved dramatically, foetal mortality at King’s, after decreasing steadily over several years to approximately 1% at the present time, is now little different from the general population.
Foot problems can occur in people with diabetes sometimes causing protracted periods of disability. During the 1960s, an orthopaedic surgeon Mr Christopher Catterall used to attend clinics weekly to assist the physicians—sessions which were forerunners of the first dedicated diabetic foot clinic (1983) setting standards for others to follow, and directed by Professor Michael Edmonds (another local resident) who has obtained worldwide recognition. Within the first three years he had reduced the amputation rate by 50%.
During the same era, patients who developed kidney failure were denied support by dialysis or transplantation on account of poor outcomes and limited resources. Dr Victor Parsons, a renal physician, working with colleagues, pioneered renal dialysis and transplantation for diabetic patients at a time when few units in the UK would offer these treatments. A renal physician now attends a joint weekly clinic to enhance increasingly effective treatments aimed to delay the onset of kidney damage.
Understanding the inheritability of diabetes has a long and confusing history. Dr David Pyke CBE (1921—2001, also a Dulwich resident,) had a major international influence in the field of diabetes. During his tenure he established the world’s largest study of identical twins, one or both of whom had diabetes—comprising up to the present some 600 twin pairs, now in the care of Professor David Leslie at St Bartholomew’s Hospital. Dr Pyke established that a genetic trait was much more prominent amongst those with Type 2 diabetes, while the genetic makeup in those with Type 1 diabetes opened the door to environmental influences still unknown. The observation of Professor Keith Taylor and colleagues that new cases of Type 1 diabetes were diagnosed more frequently during the winter months, led to the idea of a viral involvement, never however confirmed.
A new era began in 1995, with the establishment of the first professorship in diabetes in the UK to which Dr Stephanie Amiel (also a local resident) was appointed. She was the first in the UK to perform a successful islet (insulin producing cell) transplant into an insulin dependent diabetic patient for the treatment of severe hypoglycaemia, still a potential complication of insulin therapy. She has made substantial contributions first to understanding why some patients lose the protective warning symptoms of hypoglycaemia (low blood sugar) and then how to alleviate this serious problem. The department at King’s continues to be innovative, and recently established two new chairs--one in the Psychiatry of Diabetes (Professor Khalida Ismail, also living locally), and the second in Diabetes Nursing (Professor Angus Forbes), the latter funded by the Federation of European Nurses in Diabetes. Both of these appointments will enhance research and education for the benefit of patients. Lawrence cared fiercely for his patients’ wellbeing. Long after his retirement, he reviewed the outcome of 90 of his patients followed over a period of 20 - 40 years, and recorded the “joy to see how quickly such patients, including myself, were rebuilt”.
In conclusion, one may reflect on the astonishing developments through the last century, many of them taking place at King’s, by listening again to the story of Mrs. BJ: “ I had started insulin only 10 years after its discovery, but I remember meeting an elderly man telling us that he had become diabetic before insulin, and how he thanked God for it every day”.
Peter Watkins MD FRCP, formerly Consultant Physician at King’s College Hospital and a member of the Dulwich Society’s Local History Group.